complaint·August 8, 2025

During today’s visit, LPA requested copies of resident and staff rosters. At approximately 11:40am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. No full bed observed on residents' beds. Allegation: Licensee used full bed rails for non-hospice resident. It was reported and stated by RP that on 08/27/2024, s/he noticed full bed rails were installed on R1's bed. RP states s/he believes the full bed rails were placed on R1's bed as a way to restrain him and keep him in bed. RP also states the full bed rails were still in place on 09/10/2024 when they moved R1 out to another facility. To investigate this allegation, LPA conducted interviews and collected R1's records for review. Based on interviews with the facility Administrator and two (2) caregivers, it was revealed that the Resident #1 (R1) was observed attempting to get out of bed independently despite his/her health condition requiring assistance. All staff members stated that R1 was at high risk of falling from the bed. In an effort to prevent a fall, staff utilized a full bed rail on R1's bed. Staff also stated that multiple times they asked R1's POA to speak with the physician to get R1 re-evaluated and request full bed rail order if with physician's approval. POA never requested stating R1 does not need full bed rail. LPA reviewed R1's records and observed that R1 was receiving Palliative care, however, there was no physician's order for the use of full bed rail at that time. Per Title 22 regulations, the use of full bed rail without a doctor's order constitutes a violation of the regulation. Based on observations, interviews, and records review there is sufficient evidence to conclude that the above allegation is Substantiated. Deficiency issued per CA code of Regulations Title 22 on LIC-9099D Exit interview conducted, appeal rights explained, and a copy of this report signed and delivered. During today’s visit, LPA requested copies of resident and staff rosters. At approximately 11:40am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Allegation: Staff did not assist resident with transfers . It was reported that S1 refused to move R1 out of bed because S1 said s/he was not comfortable moving R1. RP stated when asked S1 to put R1 in the wheelchair so R1 could go outside during a visit, S1 refused to get R1 out of bed. To investigate the allegation LPA conducted interviews with Administrator, S1 and S2, who denied ever refusing assisting residents with transfers. Interviews also revealed that due to some residents’ heavy weight or health issues sometimes 2 caregivers assistance is required for transfers from or to bed. Staff members confirmed that resident #1 (R1) family member got frustrated and complaint that R1 did not get assistance with transfer. The family member got explained that once the second caregiver finishes the round, R1 will get assistance. However, the family member refused to wait because they wanted assistance immediately and started to verbally attack caregivers. Interview with two (2) out of four (4) residents confirmed that staff never refused assisting residents with transfers whenever they asked for. Residents also stated that since R1 moved to the facility, family members expected R1 to have 24 hours of 1:1 care and always created arguments with staff members. Residents stated that they are very happy with the care and assistance they receive from the caregivers and would never move out to another facility. During the visit LPA also observed that residents receive adequate care by caregivers and caregivers provide proper assistance with transfers. Based on the observation, records review, and interviews, there is insufficient evidence to support the allegation that the facility staff fails to assist residents with transfers. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Licensee does not provide planned activities for residents. It was reported that R1 was always in bed in the room just staring at the wall because R1 did not have a TV, and no activities were provided by staff. To investigate the allegation LPA conducted interviews with the Administrator, two (2) staff members, and two (2) out of four (4) residents who were able to communicate. Interview with staff members confirmed that, although various activities get provided to residents in care regularly, not all residents wish to participate or are capable of it, due to their diagnosis or health condition. Staff members confirmed they do morning exercises, art/coloring books, board games, memory games and music. Continue on LIC9099-C During the interview the administrator reported that his/her working hours are M/W 10am-7pm, Th-F 1pm-7pm, Sun 10am-5pm, that totals 37 hours per week, which meets the minimum requirement for administrator presence as outlined by Title 22 regulations. The administrator also added that due to his/her current condition of high-risk pregnancy, there have been occasional fluctuations in on-site hours related to frequent doctor appointments. However, s/he remains accessible via phone and is in regular communication with staff to ensure facility operations. Interview with residents revealed that the administrator is present at the facility several days each week and regularly engages in one-on-one conversations with residents to check on their well-being. Staff roster review also confirmed the administrator’s shift days and hours. Based on observation, interviews, and records review, there is insufficient evidence to support the allegation that the administrator is not present adequate hours to operate the facility . Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Licensee did not ensure staff administering oxygen to resident was appropriately trained. It was reported by RP when they moved R1 out from the facility, S1 was the only staff at the facility and s/he did not know how to connect R1’s oxygen to the oxygen tank, so R1 was without oxygen for 15 minutes, which caused R1 to have a medical episode once R1 was at the new facility. To investigate the allegation, interviews were conducted with the facility administrator, two (2) staff members, two (2) out of four (4) residents who were able to communicate, and with the Administrator where R1 transferred to. During the interview, the administrator confirmed that all staff members received training on administering oxygen to residents. The administrator also provided copies of all training materials for LPA’s review. The administrator also added that currently there is no resident in the facility who requires oxygen tank, however, Resident #1 (R1) who resided in the facility from 7/23/24 through 9/10/24 had the physician’s order to use oxygen during the nighttime and daytime as needed. LPA reviewed the oxygen and vital signs log for R1 and detected that staff followed proper procedures to monitor R1’s oxygen level daily and use the oxygen tank as needed. Although staff was providing sufficient care to R1, R1’s POA was very aggressive towards caregivers, demanding, and was arguing and verbally attacking everyone for everything. Interview with S1 confirmed that on the day when R1 was being transferred to another facility by POA and some family members, the POA asked S1 how to operate the oxygen tank and how to turn it On and Off, S1 showed the switch on the machine and explained the process that, although the machine is always connected to the power, there is a separate switch on the machine that once the nasal cannula gets installed on R1 that switch needs to get turned on as well. Continue on LIC9099-C Residents who have dementia and are mainly inside their rooms watching TV or listening to music, some residents refuse to participate in activities and staff can't force them. Staff members also stated that they always tried to engage R1 with activities, however, due to R1's mental status and severe Dementia, R1 was not interested in any of the activities provided to him/her and was always requesting to stay in bed. Interview with two out of four residents confirmed that caregivers do provide different activities during the day, for example painting, seat exercise in the morning, bingo, etc., however, they do not wish to participate every day. Residents also added that they prefer doing puzzles and other activities on their devices. During the visit, LPA observed cabinet with books, puzzles, art and craft activities, etc. Based on the observation, records review, and interviews, there is insufficient evidence to support the allegation that the facility does not provide planned activities to residents. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Licensee operated facility over capacity. It was reported that there were seven residents being cared and the licensee operated facility over capacity. To investigate the allegation interviews were conducted with the facility administrator, two (2) staff members and two (2) out of four (4) residents who were able to communicate. All parties consistently reported that the facility never operated over its approved capacity. LPA also conducted records review, including admission records, resident roster, and staffing schedule which also confirmed that the facility operated within its capacity. No documentation or evidence was found to indicate that the facility exceeded the approved number of residents at any time. Based on observation, interviews, and records review, there is insufficient evidence to support the allegation that the licensee operates or operated over the capacity. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Facility administrator is not present adequate hours to operate facility . It was reported that the owner / Licensee / Administrator was never present at the facility and RP was only able to speak with the administrator by phone. RP stated she/he believes the administrator may live out of state because s/he is not at the facility as an administrator should be to properly operate it. To investigate the allegation, interviews were conducted with the facility administrator, two (2) staff members and two (2) out of four (4) residents who were able to communicate. Continue on LIC9099-C POA and family had not arrive with non-ambulatory and/or emergency transportation, to transfer R1, and R1 had no access to the oxygen tank on the way to the other facility. S1 also confirmed that on the day of the transfer staff checked the vitals and the oxygen level was in the normal range. POA was informed that during the transfer the machine won’t operate since there is no power. The POA started falsely accusing S1 that S1 does not want to help because does not know how to connect the tank. S1 confirmed that the training was provided to her/him, and s/he is very comfortable to assist residents who require oxygen tank per doctor’s order. R1 exited the facility around 2pm. Interview with the Administrator where R1 transferred to on 9/10 2024 confirmed that R1 arrived around 4-4:30pm, was alert, had no issues with oxygen, had dinner and did not show any issues with health. The Administrator from the second facility also confirmed that R1 does not use oxygen in his/her facility. LPA also reviewed staff training materials and revealed that all staff members received the required training. Based on observation, interviews, and records review, there is insufficient evidence to support the allegation that the administrator failed to provide appropriate training to staff on administering oxygen to residents. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered.